1. PALi Cardiology Revision: Heart Failure Lucille Ramani 0707070r@student.gla.ac.uk

2. “a complex of signs and symptoms that occurs when the heart fails to pump adequate CO” Heart Failure Definition Epidemiology Prevalence: 3-20 per 1000 5% emergency admissions  by 50% in the next 25 years 50% dead by 5 years Mainly a disease of the older population (>65 years)

3. Aetiology CauseSpecific Examples Cardiovascular disease IHD; cardiomyopathies; HTN; myocarditis; valvular heart disease; congenital heart diseases Pulmonary disease Pulmonary HTN; pulmonary valve stenosis; PE; chronic pulmonary disease; neuromuscular disease Toxins Heroin; alcohol; cocaine; amphetamines; lead; arsenic; cobalt; phosphorus Infection Bacterial; fungal; viral (HIV); Borrelia burgdorferi (Lyme disease); sepsis Electrolyte imbalance  calcium, phosphate, potassium, sodium Endocrine disorders DM; thyroid disease; hypoparathyroidism; phaeochromocytoma; acromegaly Systemic collagen vascular diseases SLE; RA; systemic sclerosis; polyarteritis nodosa; Reiter’s syndrome Drug-induced Adriamycin; cyclophosphamide; sulphonamides Nutritional deficiencies Thiamine; selenium; L-carnitine Pregnancy Peripartum cardiomyopathy

4. Aetiology: – Chronic pulmonary disease  cor pulmonale – Left-sided heart failure – Patent ductus arteriosus – Isolated right-sided cardiomyopathy – Tricuspid valve disease  RV pressure  backward failure  systemic venous congestion Right Heart Failure (RHF)

5. Symptoms – Fatigue – Dyspnoea – Anorexia, nausea – Nocturia Signs –  JVP – Smooth, tender hepatomegaly – Ascites – Pitting oedema (sacral, ankle) – Hypotension – Cyanosis, cool peripheries RHF: Clinical Features

6. Ischaemic heart disease Chronic systemic HTN Cardiomyopathy (usually dilated) Mitral / Aortic valve disease – Mitral regurgitation: volume overload (  preload ) – Aortic stenosis: pressure overload (  afterload) Consequence = pulmonary congestion LHF: Aetiology

7. Symptoms – Fatigue – Dyspnoea: exertional; orthopnoea; paroxysmal nocturnal – Cough ± frothy pink sputum; haemoptysis Signs – Few, but prominent at late stage – Weight loss; muscle wasting – Cardiomegaly – Pulmonary oedema (creps) – Hypotension; cool peripheries – S3 and tachycardia: triple gallop rhythm LHF: Clinical Features

8. Compensatory mechanisms become overwhelmed and thus pathological (cardiac decompensation) Key concepts: – CO is a function of preload and afterload – Preload: end-diastolic wall stress (initial stretching of myocytes) – Afterload: the resistance against which the heart has to pump – Frank-Starling mechanism: change in SV in response to change in preload –  in preload via Rx is beneficial –  in workload and symptoms arising from venous congestion Pathophysiology

9. 1.  filling pressures to maintain SV 2.Dilation: increased wall tension  ischaemia 3.Hypertrophy to balance pressure overload 4.Sinus tachycardia 5.Neurohormonal mechanisms Activation of RAAS -  systemic vascular resistance - Aldosterone release (Na + and water retention) - ADH release (water retention)  Sympathetic activity (  catecholamines) -  HR, force of contraction and peripheral vasoconstriction Compensatory Changes

10. Diagnosis of HF (European Society of Cardiology Guidelines) Essential Features 1.Symptoms and signs of heart failure (e.g. SOB, fatigue, ankle oedema) 2.Objective evidence of cardiac dysfunction (at rest) Non-essential Features: in cases where there is diagnostic doubt 3. Response to treatment directed towards heart failure Diagnosis Bloods; cardiac enzymes/markers BNP (>100pg/mL = 95% specificity and 98% sensitivity ECG Transthoracic doppler ECHO: EF<0.45

11. ) Alveolar oedema (“Bat’s wings”) Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Pleural Effusions LV dysfunction  dilation of pulmonary vessels  leakage of fluid into interstitium  pleural effusion  alveolar oedema (pulmonary oedema) Chest X-ray Findings

12. Aims: – Treat cause, e.g. valve disease – Treat exacerbating factors, e.g. anaemia, HTN – Relieve S+S – Augment survival General Measures: – Smoking cessation – Salt reduction and fluid restriction if severe – Maintenance of optimal weight and nutrition – Vaccinations: pneumoccocal (once only) and annual influenza – Assess for depression – Monitor: functional capacity, fluid status, cardiac rhythm Management

13. Diuretics – Routinely loop diuretics, e.g. Furosemide 40mg/24h po (increase prn) – Can add spironolactone or metolazone ACEi – Long-acting, e.g. lisinopril 10mg/24h po – Start with small dose and increase every 2 weeks until at target (30-40mg) – Warn patients of side effects: hypotension (esp after first dose- advise to lie down); dry cough; hyperkalaemia; taste disturbance – Check U+E and creatinine before starting and with each titration Pharmacological Rx

14. Beta-blockers – Initiate after ACEi and diuretic – Start low, go slow e.g. carvedilol 3.125mg/bd  25-50mg/bd (at least 2 week increments) Angiotensin-II receptor antagonists – Alternative if intolerant of ACEi Digoxin – Use if diuretics, ACEi or BB do not control symptoms or if in AF – 0.125mg-0.24mg/24h po – Monitor U+E and maintain potassium at 4-5mmol/L Pharmacological Rx

15. Most commonly occurs in context of acute MI  extensive loss of ventricular muscle – Also: PE, cardiac tamponade, rupture of IV septum (producing VSD), AF Clinical presentation: – Acute worsening (decompensation) of chronic HF – Acute pulmonary oedema: respiratory distress, crackles, pink frothy sputum – Cardiogenic shock: hypotension, tachycardia, oliguria Investigations: – CXR – ECG; consider ECHO and BNP – U+E; cardiac markers; ABGs Acute HF

16. Different to chronic; Rx before Ix Sit pt up + high-flow O2 (100% if no lung disease) IV access and ECG (Rx any arrhythmia, e.g. AF) Diamorphine 2.5-5mg IV slowly Furosemide 40-80mg IV slowly GTN spray 2 puffs sublingual then infusion of isosorbide dinitrate 2-10mg/h If pt worsening- first get help, then: – Further dose of furosemide – Consider ventilation or increasing nitrate infusion Acute HF Management

17. MEQ 1.2 A 78 year old man had a large anterior myocardial infarction 3 years ago. Initially he made a good recovery although he has required to take a diuretic for ankle swelling since. In the last 2 months he has become short of breath on exertion. You suspect he has developed left ventricular failure Marks (a)Give 2 additional symptoms which would support this diagnosis 2 (b)You arrange for a chest x-ray. Give 4 features which would support the diagnosis of left ventricular failure 4 (c)Give 2 neurohumoral mechanisms which may be activated in heart failure 1 (d)If starting this patient on an ACE Inhibitor give 3 precautions you would take 3 MEQ Past Paper

18. What are the possible causes for deterioration in HF? (3) Immediate treatment of acute HF and how you would administer this? (3) Further Questions

19. Any Questions? Thank-you!